079200792-2-13-2024-15-AS-CFOR-D2F2T3-20240213164005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200792
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:40:18 PM

Document Has Been Signed on 02/13/2024 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	APPLEWOOD RESIDENCE LLC		FACILITY NUMBER:	079200792
ADMINISTRATOR:	ARACELI S. EMERICK		FACILITY TYPE:	740
ADDRESS:	5123 ESMOND AVE		TELEPHONE:	(650) 722-2381
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94805
CAPACITY:	6	CENSUS: 4	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	ANITA SERNA, CAREGIVER		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 2:08PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Members, Anita Serna, Caregivers. Araceli Emerick, Administrator arrived at approximately 2:50PM. LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to residents. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Medication was centrally stored and secure. LPA reviewed 4 of 5 resident records, which were all complete. LPA reviewed a sample of staff records. LPA reviewed 4 staff files. Staff files were complete. Administrator's Certificate# (6047865740) was current with an expiration date of 04/10/2024 The facility conducted fire and evacuation drill on 1/5/2024. Facility's fire extinguishers were last inspected 04/27/2023. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: APPLEWOOD RESIDENCE LLC	FACILITY NUMBER: 079200792
	VISIT DATE: 02/13/2024

NARRATIVE

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Continued from LIC809

LPA requested the following documents to update facility file:

· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Updated Liability Insurance

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Friday, 02/23/2024.

Deficiencies observed by LPA during tour:

At 2:13PM LPA observed broken lock on knife cabinet.
At 2:14PM LPA observed knives in an unlocked drawer in the kitchen.
At 2:29PM LPA observed unlocked scissors in china cabinet, first-aid cabinet unlocked.
At 2:35PM LPA observed unlocked medication in first-aid cabinet.
At 2:45PM LPA observed uneven brick pavement located in the backyard.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809 & 809C, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to staff.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: APPLEWOOD RESIDENCE LLC	FACILITY NUMBER: 079200792
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by having a broken lock on the knife cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a lock for the kitchen cabinet, keep the knives locked. Administrator will email photo copies to CCLD no later then the POC date,

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked medications in the first-aid cabinet which poses an immediate health risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Administrator agreed to read regulation and conduct in-service with staff and submit names and signature of attendees to CCL by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: APPLEWOOD RESIDENCE LLC	FACILITY NUMBER: 079200792
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having uneven brick pavement located in the backyard which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Administrator agreed to get brick pavement repaired and submit photo copies to CCL by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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